CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Medication Therapy Management Program (MTMP) Coverage Criteria

Defines eligibility, services, and processes for the Medication Therapy Management Program offered at no cost to eligible members of the Blue Cross Blue Shield - South Carolina plan. Affects members who meet enrollment criteria and providers/pharmacists delivering MTM services.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyMedication Therapy Management Program (MTMP) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvide an annual Comprehensive Medication Review with an individualized written Medication List and Recommended To-Do List to invited eligible members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

AnnualCMR frequency

QuarterlyTMR frequency

8+Maintenance drugs threshold

3+Chronic conditions threshold

$135.25Cost threshold

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Enrollment & Services Eligibility

Automatic enrollment criteria

Members are automatically enrolled at no cost if they meet either of the following:

Automatic enrollment pathways: Either be in a Management Program to help manage and safely use medications such as opioids and benzodiazepines

Enrollment is at no cost to the member

Eligibility based on drug use, chronic conditions, and cost: Member takes eight or more Medicare Part D covered maintenance drugs (>= 8), AND has three or more specified chronic health conditions, AND exceeds an average of $135.25 per month in prescription drug costs by member and plan combined

Chronic conditions list: Alzheimer’s disease; Respiratory disease (including asthma, COPD, and other chronic lung disorders); Mental health (including depression, schizophrenia, bipolar disorder, and other chronic disabling mental health conditions); Chronic congestive heart failure (CHF); Diabetes; High blood pressure; High cholesterol; Bone disease/arthritis (including osteoporosis, osteoarthritis, and rheumatoid arthritis); End-stage renal disease (ESRD); HIV/AIDS

Services included

MTMP provides the following services to eligible members:

Comprehensive Medication Review (CMR) components: Annual interactive person-to-person consultation performed by a qualified provider, review of medications (may be person-to-person or via algorithms), and an individualized written summary including a Medication List and Recommended To-Do List

CMR is offered at least annually to eligible members and the consultation typically takes about 30 minutes

Targeted Medication Review (TMR) components: Quarterly targeted medication reviews that assess medication profiles for duplicate therapy or drug-disease interactions and may generate member-specific reports to prescribers; any changes to therapy occur only if the member and prescriber agree

TMRs are conducted quarterly

Participation in the Medication Therapy Management Program (MTMP) is voluntary. Enrollment is by invitation only and the program is not a benefit available to all members. Being invited to participate does not change a member’s existing coverage and there is no cost to the member for MTMP services.

Enrollment Thresholds & Codes

Minimum number of Part D covered maintenance drugs

Minimum Part D maintenance drugs>= 8 Medicare Part D covered maintenance drugs

ContextThreshold is one of three conditions required for automatic enrollment into MTMP

Source noteListed under automatic enrollment criteria in program qualification section

Number of chronic conditions required

Required chronic conditions>= 3 chronic health conditions from the enumerated list

Examples includedAlzheimer's disease; Respiratory disease (asthma, COPD); Mental health disorders; CHF; Diabetes; Hypertension; High cholesterol; Bone disease/arthritis; ESRD; HIV/AIDS

Documentation, Prior Auth & Operational Notes

Prior Authorization

Prior Authorization Not Required

Prior authorization is not applicable to Medication Therapy Management (MTM) services. MTM services (including Comprehensive Medication Reviews) are offered at no cost to invited members and do not require prior authorization through the plan.

Step Therapy

No Step Therapy Requirement

There are no step therapy requirements for enrollment in or receipt of MTM services. Participation is voluntary and by invitation; members are not required to meet any step-therapy sequencing to receive MTM or CMR services.

Documentation Required

CMR Documentation Requirements

Comprehensive Medication Review (CMR) documentation must include an individualized, written summary provided to the member. The CMR includes a Medication List and a Recommended To-Do List that are given to the member after the consultation.

Key Program Definitions

Comprehensive Medication Review (CMR) - definition and scope

DefinitionA Comprehensive Medication Review (CMR) is a review of a member's medications including prescription, over-the-counter (OTC), herbal therapies, and dietary supplements to assess medication therapy and optimize outcomes.

ScopeIncludes an interactive, person-to-person consultation performed by a qualified provider at least annually and an individualized written summary (Medication List and Recommended To‑Do List).

SettingsCMR may be conducted in-person or by phone (often by a pharmacy or call center pharmacist).

Targeted Medication Review (TMR) - quarterly assessment definition and common triggers

DefinitionA Targeted Medication Review (TMR) is a quarterly assessment of medication profiles focused on issues such as duplicate therapy or drug–disease interactions.

Process and triggers

Program Background

Medication Therapy Management (MTM) is a pharmacist-led set of services designed to identify medication-related problems, optimize therapy, and improve outcomes. MTM includes two primary activities: the Comprehensive Medication Review (CMR), an annual interactive, person-to-person consultation performed by a qualified provider that reviews all medications (prescription, over-the-counter, supplements and herbal therapies) and results in an individualized written summary (including a Medication List and Recommended To‑Do List), and Targeted Medication Reviews (TMRs), which are conducted quarterly to screen medication profiles for issues such as duplicate therapy or drug–disease interactions and may generate member-specific reports to prescribers.

Where Services Are Delivered

Note

CMR by phone or in-person (phone reviews often by pharmacy/call center pharmacists)

CMRs may be conducted either by telephone or in person; members will be offered a choice and phone reviews are frequently performed by a pharmacy or call center pharmacist.

Member is given the option of in-person or phone review.
Call center or pharmacy pharmacists commonly conduct phone CMRs.